HomeMy WebLinkAboutApp-Permit-ComplianceN c�l�l-z3�� 6L1J�--L9- 0oaZ33
No.
,,40M SON LTIJ OF MASSACHUSETTS
FEE,
. 0����
IelZv I " ' Board of Health, `Y ��'1 _ a f MA.
APPLICATION.FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Constru Repair( ) Upgrade( ) Abandon( ) �omplete System O individual Components
Locations
Owner's Name
294
Map/Parcel#
Address
Lot# �
Telephone#
Installer's Name e �f Sof
Designer'sNamee
Address %
Address 3 7
Telephone#
Type of Building' _ - - Lot Size sq. ft.
Dwelling- No. of Bedrooms Garbage grinder
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min, required) D gpd Calculated design flow Design flow provided % gpd
Plan: Date Number of sheets ! Revision Date
Title
Description ofSoil (s)'.
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
The: undersigned agrees to
further agrees to no
`Signed
Inspections
t 5 1 I�T P,-
0scribed Individual Sewage: Disposal System.in accordance with the provisions of TITLE 5 and;
operation until a Certificate of Co ' e has been issued by the Board of Health.
Date _ kar `yG
ib
.e_
.,eta_
is C -C-14
C:1G
iz4 °i�-
:No. {.� � SF C `� � (/•.+ X.J � C®1' Al' I®1 V Y V 9:L riLTJLJL OF 1.' llAS �:YAOY>� � f% ryi,� l C� � �� n � �i .
J^pgL
1� O c
Board of Health, & 6l
CERTITICATE'OF COMPLIANCE
Description -of Work: 0Individual Components) plete System
The undersigned hereby certify that the Sewage Disposal System; Constructed Repa red ( ), Upgraded ( ), Abandoned ( ),
by: ! .� c t�11 1 <._ [ ; T� ai'I'� t } c
has been installed in accordance with the s ozas of 310 .CMR :15.00 (Title 5) and th�:a proved design plans/as-built plans relating to.
application No��, dated Approved Design Flow 1 (gpd)
Installer �.( _" ( ; �)
Designer: IQLD i`3 C ek C+ J% l N, Inspector: Date.: .
The issuance of thispermit shall not be construed as a guarantee that the system will function as :designed.
No. b 0A V ' (t "' 6 jf i� � s 1 FEE g �1
COMMONWEALTH Of MASSAC14USETTS
Board of Health,
DISPOSAL SYSTEM CONSTRUCTION
Permission is hereby granted to; ConstructX Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
atfc'_1 TedCSC? LA�Cas described in the application. for
Disposal System Construction Permit No. dated '
Provided: Construction shall be completed withit the date of this t, All local conditions must be met:
Farm 1255 Rev. 5/96: A.M. SWkin Co. Charlestown, MA D'dte / Board of Health